Get Newborn La Medicaid Form

This guide provides clear instructions for completing the Newborn La Medicaid Form online. By following these steps, you can ensure that all necessary information is accurately submitted for your newborn's Medicaid enrollment.

Follow the steps to successfully complete the Newborn La Medicaid Form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In Part I, complete the section designated for the hospital. Provide the mother's name and Medicaid number, which consists of a 13-digit Medicaid person number. Enter the date of admission, the mother's date of birth, social security number, city, mailing address, state, phone number, parish of residence, and zip code. Ensure all information is typed or printed legibly.
3. After the child’s birth, complete Part II. Enter the newborn’s name, including first name, middle initial if applicable, and last name. Select the newborn’s sex by marking 'M' for male or 'F' for female. Include the newborn's date of birth and indicate if the baby is Twin A or Twin B along with the newborn’s race.
4. If applicable, provide special notes regarding the newborn's status (e.g., NICU admission). Input adoption details or information regarding any expired status, including the date of death, if relevant. Ensure to clarify if this is a corrected copy and indicate what is being corrected.
5. Fill out the hospital's name, contact information, and address in the designated fields. Provide phone and fax numbers, ensuring they are accurate for billing purposes.
6. List the names and contact information of the baby’s attending physician, pediatrician, and any other healthcare providers. This includes their phone, fax, state, city, address, and zip code.
7. Indicate whether the newborn will live with the mother upon release from the hospital by selecting 'Yes' or 'No.' Also, answer whether an application has been made for a social security number and if the mother has private health insurance coverage.
8. A facility representative must sign and include their phone number and the date of signature in the last section of Part I.
9. Part III will be completed by the BHSF (Bureau of Health Services Financing). Here, they will indicate the newborn's Medicaid eligibility status, and provide additional required information such as the newborn's Medicaid person number, effective date of eligibility, the signature of the BHSF representative, and the BHSF representative's phone number and date.
10. Once you have filled in all sections of the form, review all your entries for accuracy. You can then save the changes, download, print, or share the form as necessary.

Complete your Newborn La Medicaid Form online today to ensure timely processing of your newborn's Medicaid enrollment.